Request for Payment of Federal Benefit by Check, EFT Waiver Form

Forms and Documents

Document Name	Status
Form FS Form 1201W-DFAS EFT Waiver Form - DFAS Form and Instruction	New
Form FMS 1201W (SP) EFT Waiver Form Form and Instruction	Modified
1510-0077_SS_Wavier_REV_03JUN14.doc Supporting Statement A	2014-06-03
Justification_for_Change_DFAS_15MAY2014.doc Justification for No Material/Nonsubstantive Change	2014-05-22

IC Document Collections

IC ID	Document Title	Status
211679	EFT Waiver Form - DFAS Form and Instruction	New
202118	EFT Waiver Form Form and Instruction	Modified

ICR Details

OMB Control No: 1510-0077	ICR Reference No: 201405-1510-002
Status: Historical Active	Previous ICR Reference No: 201401-1510-001
Agency/Subagency: TREAS/FMS	Agency Tracking No:
Title: Request for Payment of Federal Benefit by Check, EFT Waiver Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/03/2014
	Date Received in OIRA: 05/22/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2015	07/31/2015	07/31/2015
Responses	3,250	0	3,000
Time Burden (Hours)	1,083	0	1,000
Cost Burden (Dollars)	1,380	0	1,380

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Abstract: 31 CFR part 208 requires that all Federal non-tax payments be made by electronic funds transfer (EFT). This form is used to collect information from individuals requesting a waiver from the EFT requirement because of a mental impairment and/or who live in a remote geographic location that does not support the use of EFT. These individuals may continue to receive payment by check. However, 31 CFR part 208 requires individuals requesting one of these waiver conditions to submit a written justification.

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Authorizing Statute(s): US Code: 31 USC 3332 Name of Law: Required Direct Deposit
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 77590	12/13/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 26605	05/04/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
EFT Waiver Form	FMS 1201W (SP), FS Form 1201W	Solicitud Para Recibir Su Pago de Beneficios Federales En Cheque ,   Request for Payment of Federal Benefits by Check
EFT Waiver Form - DFAS	FS Form 1201W-DFAS	Request for Payment by Federal Benefits Check

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,250	3,000	0	250	0	0
Annual Time Burden (Hours)	1,083	1,000	0	83	0	0
Annual Cost Burden (Dollars)	1,380	1,380	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The Defense Finance and Accounting Service (DFAS) has asked Treasury to assist them in reviewing and approving or rejecting requests by their recipients of a military benefit to continue receiving payment by check. The DFAS has requested minor changes to the form to accommodate the use by this category of recipient. The Bureau of the Fiscal Service (FS) will offer DFAS users the FS 1201W-DFAS, which is the same as the FS-1201W except for a few modifications to accommodate military benefits recipients. A check box selection for the type of recipient receiving the military benefit has been added and the recipient would identify the social security number of the deceased person if annuitant or former spouse. We estimate an additional 250 DFAS respondents and an additional 83 burden hours.

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Annual Cost to Federal Government: $1,320

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/22/2014

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